H. pylori: a proton pump inhibitor plus 2 antibiotics was effective eradication therapy

Clinical bottom line (level 2a)

  1. The most effective H. pylori eradication therapies were
    • proton-pump inhibitor plus 2 of macrolide, nitroimidazole or amoxicillin
    • bismuth compound plus nitroimidazole plus tetracycline
Unge and Berstad: Scandinavian Journal of Gastroenterology 1996; 31 (220): 27-40
Expires November 2002

The study

Systematic review of all randomised or cohort studies of
  • Patients: H. pylori infection
  • Intervention:
  • Outcome:
Articles found in ?English using Medline, to 1995 (search terms: not given ) and searching abstracts from international gastroenterology meetings

Selection criteria:
Appraisal criteria: not given: analysis was by intention-to-treat
Articles excluded if:
  • no defined protocol, treatment regimen or assessment methods for H. pylori
  • serology used to detect H. pylori
  • dual therapy (except those with omeprazole)


515 studies found

The evidence

  • pooled eradication rates
    • bismuth + nitroimidazole + amoxicillin: 75% (95% CI: 71% to 79%)
    • bismuth + nitroimidazole + tetracycline: 82% (95% CI: 80% to 84%)
    • bismuth + nitroimidazole + amoxicillin + H2 antagonist: 65% (95% CI: 53% to 77%)
    • bismuth + nitroimidazole + tetracycline + H2 antagonist: 68% (95% CI: 59% to 77%)
  • H2 antagonist + amoxicillin + nitroimidazole: 65% (95% CI: 59% to 71%)
  • proton-pump inhibitor triple therapy
    • omeprazole + amoxicillin + nitroimidazole: 84% (95% CI: 81% to 87%)
    • omeprazole + amoxicillin + macrolide: 85% (95% CI: 82% to 89%)
    • omeprazole + nitroimidazole + macrolide: 87% (95% CI: 83% to 90%)
    • lansoprazole + amoxicillin + nitroimidazole: 82% (95% CI: 67% to 97%)
    • lansoprazole + amoxacillin + macrolide: 80% (95% CI: 64% to 96%)
  • The confidence intervals provided are calculated by taking the confidence intervals of the simply pooled data and enlarging by 50%.

Comments

  1. Although not a formal meta-analysis, this review pools data from 515 studies to try and pick a 'best buy' regimen for the eradication of H. pylori.
  2. Variable number of studies and of patients in studies means that the strength of evidence for or against various regimens varies widely.
  3. Efficacy, in terms of H. pylori eradication, is the sole outcome measure but the use of 'intention to treat' analysis ensures that differential adverse effect profiles are taken care of, to an extent.
  4. The ideal regimen has not yet been identified but a proton pump inhibitor plus a macrolide plus either amoxacillin or a nitroimidazole looks like the current 'best buy', though only by a small margin.

Citation

  1. Unge P, and Berstad A: Pooled analysis of anti-Helicobacter pylori treatment regimens (supplement). Scandinavian Journal of Gastroenterology 1996; 31 (220): 27-40
Search Terms: pylori in Cochrane
Contributor: Chris Ball and Musab Hayatli, November 1999
Reviewer:

Clinical Question.
Patient H. pylori infection
Intervention or Exposure eradication therapy
Outcome eradication